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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366423573
Report Date: 07/24/2023
Date Signed: 07/24/2023 10:08:53 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/12/2023 and conducted by Evaluator Rayshaun Nickolas
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230712081555
FACILITY NAME:KAISER SPECIALIZED RESIDENTIAL SERRANOFACILITY NUMBER:
366423573
ADMINISTRATOR:REBA JORDANFACILITY TYPE:
735
ADDRESS:16146 SERRANO AVETELEPHONE:
(760) 242-5759
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY:4CENSUS: 4DATE:
07/24/2023
UNANNOUNCEDTIME BEGAN:
09:52 AM
MET WITH:Kassandra Runde, DSPIITIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Facility staff hits resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rayshaun Nickolas visited the facility unannounced to deliver the finding on the above allegation. LPA met with DSP II Kassandra Runde and explained the purpose of the visit. The investigation included file review, facility tour, and interviews with relevant parties.

The allegation alleged that several facility staff members hit resident #1 (R1). LPA Nickolas’ interview with R1 confirmed the allegation. LPA Nickolas’ interview with resident #2 (R2) revealed that R2 likes living at the facility. R2 also denied facility staff members hitting them or observing them hitting other residents. LPA Nickolas interviewed six (6) facility staff members about the allegation, and all staff interviewed denied the allegation. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

A finding of Unsubstantiated means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 56-AS-20230712081555
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: KAISER SPECIALIZED RESIDENTIAL SERRANO
FACILITY NUMBER: 366423573
VISIT DATE: 07/24/2023
NARRATIVE
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LPA Nickolas completed an exit interview, where this report was discussed. LPA Nickolas' also provided Runde with a copy of this report.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2